PR-242: Services Not Provided by Network or Primary Care Providers
The plan says the care came from a provider outside its network, or outside the patient's primary care setup. Before you bill the patient, check whether a referral, an exception or a surprise billing rule applies.
What PR-242 Means
The official wording for code 242 is "Services not provided by network/primary care providers." The plan is saying the patient saw someone it does not cover for this service. It is common with HMO and EPO plans, which pay little or nothing out of network.
The PR group code means the plan says the patient is responsible. With CO-242, the same reason is your write-off under your contract.
Why It Happens
| Cause | What to check |
|---|---|
| You are not in network for that plan | Many practices are in network for a payer's PPO but not its HMO or marketplace plans |
| Credentialing was not finished | Your effective date was after the date of service |
| Wrong NPI or tax ID on the claim | The billing or rendering NPI does not match the one the plan has on file |
| The HMO needed a PCP or referral | The patient went to a specialist without the required referral |
| The patient changed plans | The new plan uses a different network |
Can You Bill the Patient?
Sometimes. Check these first:
- Are you really out of network? If you are in network, the denial is the plan's error. Appeal it.
- Was it an emergency? The No Surprises Act bars balance billing for emergency care.
- Was it at an in-network hospital or surgery center? Out-of-network doctors there often cannot balance bill, and anesthesia, radiology, pathology and emergency medicine never can.
- Did the patient choose out-of-network care knowingly? Then the patient usually owes it under the plan.
See our No Surprises Act guide for the patient protections.
How to Fix a PR-242 Denial
- Confirm network status for that exact plan and date in your contract and the payer directory.
- Check the NPI and tax ID on the claim against your credentialing record.
- Fix referral gaps. If the HMO needed a referral, ask the PCP for one. Some plans accept a late referral.
- Fix credentialing gaps. Ask the payer to back-date your effective date if your application was pending. Our credentialing team can help.
- Appeal with proof of network status, the referral, or an approved exception, within the payer's appeal window.
PR-242 vs Similar Denials
| Code | What it means |
|---|---|
| PR-242 | Out-of-network or non-PCP provider; patient responsibility |
| CO-242 | Same reason; the provider writes it off |
| CO-197 | A required prior authorization was missing |
| PR-204 | The service is not covered under the patient's plan |
| CO-31 | The payer cannot find the patient at all |
How to Prevent PR-242
- Check the plan type (HMO, EPO, PPO) and your network status for that exact plan when you schedule.
- Ask HMO patients for their PCP and referral before the visit.
- Keep credentialing and payer directories up to date, and track every effective date.
- Collect a signed financial policy for patients who choose out-of-network care.
Frequently Asked Questions
Reviewed by Hassan Raza Awan, Founder — 4+ years of hands-on U.S. medical billing experience. General billing information — verify against current CMS guidance and your payer contracts.
Appealing this denial? Check your appeal deadline with our TFL calculator.
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